Occupational Health Department
OCCUPATIONAL HEALTH
UNIVERSITY HOSPITALS BIRMINGHAM N.H.S. FOUNDATION TRUST
PRE-PLACEMENT HEALTH QUESTIONNAIRE
C O N F I D E N T I A L
NAME OF APPLICANT:......
Please return completed form to:-
Occupational Health
University Hospitals Birmingham NHS Foundation Trust
Old Queen Elizabeth Hospital
3rd Floor North Block (South Corridor)
Mindlesohn Way
Edgbaston
Birmingham
B15 2TH
PLEASE READ THE WHOLE DOCUMENT CAREFULLY
Purpose of Pre placement Health Questionnaire
This questionnaire will be used by the Occupational Health Department to advise on whether adaptations, support or restrictions are required to undertake the duties of the post for which you have applied. No information regarding your health is disclosed to anyone else without your written permission.
Failure to disclose information fully or accurately may lead to termination of employment. It is a legal requirement that you fully disclose all information in relationship to your health
Disability
The employment of disabled teachers can make an important contribution to the overall school curriculum, in terms of raising the aspirations of disabled pupils and educating non-disabled people about the reality of having a disability.
Confidentiality
The information you give will be stored on the dedicated Occupational Health electronic patient record system, and will be treated in strictest confidence by the Occupational Health staff according to the rules set out in the Data Protection Act (1998). In accordance with this Act you may have access to your records at any reasonable time. If you require a copy of any part of your record this will only be supplied following a written request made to the Occupational Health Department.
I declare that I have read and understand the information.
Signature:...... Date:......
CONFIDENTIAL
PLEASE READ AND COMPLETE EACH SECTION CAREFULLY
IMPORTANT NOTE FOR OCCUPATIONAL HEALTH: Any correspondence in connection with this questionnaire must be returned to the address below:-
Occupational Health
University Hospitals Birmingham NHS Foundation Trust
Old Queen Elizabeth Hospital
3rd Floor North Block (South Corridor)
Mindlesohn Way
Edgbaston
Birmingham
B15 2TH
Telephone: 0121 371 7170
Email Address:
SECTION B
TO BE COMPLETED BY THE APPLICANT
PERSONAL DETAILS JOB/POST APPLIED FOR: ………………………..
Surname:...... Forename(s)......
(Preferred title, if any, e.g: Mr/Mrs/Miss/Ms/Dr)
Previous Name (if applicable):......
Male/Female:...... Date of Birth:......
Address:......
Post Code:...... Telephone Number:......
General Practitioners Name......
Address:......
Telephone Number of Surgery:......
NEW SCHOOL CONTACT DETAILS
School:……………………………………………………………………….………………..
Contact name:……………………………………………………………………………….
Job Title……………………………………………………………………………………….
Address:......
Post Code:...... Telephone Number:......
WORK HISTORY - DURING LAST 5 YEARS
Employer/College / Nature of Work / Start Date / Finish Date
MEDICAL HISTORY
Have you had any illness/injury which has kept you from your usual activities, whether these be work, domestic or leisure for more than10 days in the last 2 years? YES NO
If ‘YES’ please list all those illnesses below:
Reason / Approximate Dates / Length of AbsenceYes/No / Dates/Details/Current/ Resolved
1. / Do you have a physical or mental condition which has a substantial effect on your ability to carry out normal day to day activities, and which has lasted, or is likely to last more than 12 months? (Equality Act 2010)
2. / Do you need any special aids/adaptations to assist you at work, whether or not you have a disability?
3. / Have you been retired from a post or rejected for employment on grounds of ill health?
4. / Have you ever suffered from a work related injury or disease requiring treatment of any kind?
5. / Are you colour blind?
6. / Do you have any problems with your vision in either eye not corrected by glasses?
7. / Do you have any hearing difficulty?
8. / Do you smoke?
If yes, how many cigarettes per day (or ozs/week of tobacco)?
9. / Do you, or have you ever suffered from aches or pains in your joints or muscles?
10. / Have you ever suffered from any back or neck problems?
11. / Have you ever suffered from any chest ailments/asthma/bronchitis?
12. / Do you have any skin condition? eczema/ psoriasis/dermatitis?
13. / Do you have any known allergies?
14. / Have you at any time, suffered from fits, faints or blackouts
15. / Have you ever suffered from diabetes?
If ‘yes’ are you on medication?
Have you suffered any hypoglycaemic episodes in the last year?
16. / Have you ever suffered from stress, anxiety, depression or any other mental disorder?
17. / Have you ever taken a drug overdose, tried to harm yourself or attempted suicide?
18. / Have you suffered from any illness requiring psychotherapy in the last 5 years?
19. / Have you suffered from an eating disorder of any kind?
20. / Have you ever been admitted to or attended hospital?
21. / Have you attended or had treatment from any doctor, therapist or counsellor in the last 2 years?
22. / Have you taken any tablets or other medicine in the last 6 months?
23. / Are attending or waiting to attend, hospital for treatment or surgery?
24. / Height / Weight
DECLARATION
I declare that, to the best of my knowledge, all the answers and statements I have given are true.
Signature: Date:Print Name:
New School:
Address:
CONSENT TO OBTAIN MEDICAL RECORDS
TO BE COMPLETED BY ALL APPLICANTS
In order to assess your fitness to work, it may be necessary for the Occupational Health Service to seek additional information to that you have supplied. You will be informed in writing if this action is necessary. This consent is limited to applications relating only to this post/course.
Before you sign in the space below you should be aware that you have certain rights under the Access to Medical Reports Act 1988.
In summary, these rights are:-
1. To withhold your consent for an application to be made to a doctor.
2. To see a medical report before it is supplied to the Occupational Health Department (WITHIN 21 DAYS).
3. To ask the doctor to amend any part of the report which you consider is misleading or inaccurate.
4. If the doctor declines to amend any part of the report, to attach a written statement giving your views on its contents; or
5. To withhold your consent to the report being supplied to the Occupational Health Department.
NB: The doctor may withhold from you sections of the report if he or she thinks you would be seriously harmed by seeing it.
I have read and understood the above information on the Access to Medical Reports Act 1988 and hereby give my consent for the Occupational Health Department to apply for a report giving medical information from my G.P. or another named medical specialist. *
*Please give names and addresses of any other named specialist from whom you are willing for us to obtain a report.
I understand that a copy of this consent form will be sent to that doctor and shall have the validity of the original.
I do/do not* wish to see the medical report before it is sent to the Occupational Health Department. *Delete as appropriate.
Name and address of doctor/consultant to be contacted
Address / Address
Tel No / Tel No
Signature: / Date:
Name:
Address:
Post Code:
GUIDANCE NOTES ON PRE-PLACEMENT HEALTH DECLARATION FORM - TEACHERS
1. Following an interview, the Head Teacher should write to the successful candidate making an offer of appointment and enclosing the pre-employment health questionnaire, and enclose a stamped addressed envelope marked ‘CONFIDENTIAL PRE PLACEMENT HEALTH QUESTIONNAIRE’ for return of the questionnaire.
2. Please ensure that the pre-employment is sent to the new employee as soon as possible to ensure medical clearance is received before the contract of employment starts.
3. The successful candidate should complete the questionnaire. And return this to The Occupational Health Dept, Woodlands Nurses Home, Selly Oak Hospital, Raddlebarn Road, Selly Oak, B29 6JF. The questionnaire must not come back to the school.
4. On receipt of the questionnaire Occupational Health will advise the schools whether the employee has been successfully cleared for employment.
Any queries relating to this advice should be addressed to the employing school.Under no circumstances should the questionnaire be returned to the school or Schools HR Services this questionnaire is STRICTLY CONFIDENTIAL and for use of Occupational Health ONLY.